Prior Authorization Systems Pharmacist (Medtech)

TL;DR

Prior Authorization Systems Pharmacist (Medtech): Designing and configuring prior authorization criteria and decision logic for a health technology platform with an accent on clinical intent translation and system quality assurance. Focus on building complex decision trees, validating authorization pathways, and ensuring regulatory compliance of member communications.

Location: Remote (US) or Hybrid in New York, NY; Denver, CO; or Charlotte, NC

Salary: $101,600 - $160,000 USD

Company

Enterprise health technology company providing comprehensive PBM and health benefit management solutions for employers and health plans.

What you will do

• Build and configure decision trees and question sets for prior authorization review.
• Perform comprehensive QC and QA validation of authorization logic through scenario-based testing.
• Manage the mapping and validation of member and prescriber letter templates to ensure regulatory compliance.
• Develop and maintain policies for clinical criteria, denial verbiage templates, and audit processes.
• Collaborate with external clients for delegated clinical PA systems services and manage vendor relationships.
• Identify reporting needs and coordinate with stakeholders to develop PA reports.

Requirements

• Active, unrestricted pharmacist license required.
• 3+ years of health plan or PBM pharmacy experience required.
• Strong clinical background and presentation skills.
• Proficiency in Microsoft Excel and Word for structured data analysis.
• Experience supporting system testing (UAT, regression, or configuration validation).
• Ability to troubleshoot workflow issues and communicate with technical stakeholders.

Nice to have

• Client facing experience.
• Experience managing utilization management (UM) criteria.

Culture & Benefits

• Comprehensive medical, pharmacy, dental, and vision insurance.
• 401(k) plan with company match after one year of employment.
• Paid time off, sick time, and paid holidays.
• Short-term and long-term disability insurance.
• Employee assistance and wellness programs.